Secondary Syphilis in Tattoos: The Chicken or the Egg?

Granulomatous dermatitis within tattoos is most often attributed to pigment reactions, infection, or sarcoidosis. We report 2 patients of secondary syphilis presenting as granulomatous inflammation confined to black tattoo ink, an uncommon manifestation. Both patients demonstrated histologic features of granulomatous dermatitis with plasma cells, spirochetes confirmed by special staining, and complete resolution after penicillin therapy. These patients highlight syphilis as an important consideration in the differential diagnosis of papules within a tattoo.